Modalities
Working with postural
asymmetries
Suzanne Hughes AdvDip R M (Myo) looks at some tools to treat our clients more effectively
and give them some control over dysfunctional postural patterns.
A
s massage therapists or myotherapists working with human
bodies over many years we begin to see familiar patterns in
our clients. Right sided low back pain, neck pain, protracted
right scapula, overactive right SCM, overactive left
Piriformis, pain referral from myofascial triggers in QL and glut medius
more often on the right are just some of the common presentation to my
practice.
For all our good work in treating muscle imbalances and painful
tissues, our clients invariably return at some future time with the same
pain patterns or dysfunction. Understanding why these muscle
imbalances persist and how they affect the way we function can give
us the tools to treat our clients more effectively and give them some
control over dysfunctional postural patterns.
The Postural Restoration Institute (PRI) was established in 1999 to
explore and explain the science of postural adaptations and asymmetrical
patterns in the human body. Postural restoration is an innovative
treatment approach developed by Ron Hruska. It involves treating the
whole body with muscle activation exercises, manual techniques and
breathing to reverse compensatory patterns and inhibit overactive
chains of muscle.
Asymmetry
The human body is not symmetrical. We have a large liver on the
right and a heavy heart on the left. The right lung has three lobes while
the left has two lobes. The diaphragm, which has two domes, is larger
and more domed on the right, supported by the liver, whereas the left
hemi-diaphragm is smaller and flatter. Asymmetries are commonly seen
in the face with one side smaller, higher eyebrow, ear etc. on one side.
The neurological, respiratory, circulatory, muscular and vision
systems are not the same on both sides of the body. The two hemispheres
of the brain control opposite sides of the body, the left being more
dominant. The right vagus nerve is longer than the left.
Common compensatory pattern
As humans we stand with our weight mainly on the right lower
extremity. This offsets the weight of the left upper chest and leads to a
tendency for the left side of the pelvis to tilt forward, the right shoulder
to move downward and abdominals on the left to be weaker than on the
right.
These patterns of asymmetry can be seen in the way we stand, move
our extremities, walk, and breathe and the position of our jaw and teeth.
The common compensatory pattern has been described by many
authors and several explanations have been postulated:1
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• Left brain dominance causes right hand and foot motor dominance
which through repetitive use is thought to cause the common
compensatory pattern.
• Left side vestibular dominance has been shown to relate to the
position of the foetus in utero in the third trimester. Delivery in
labour commonly occurs with the left side occiput anterior.
• A study has shown that less than 12 per cent of infants’ heads are
symmetrical with a tilt of the occiput creating a tilt of the sacrum to
the same direction. Some of this distortion persists into adulthood
and will also produce an unequal distribution of weight between
lower extremities.
• Zink2 postulates that adaptation during child development,
resulting from minor traumas of the lumbar spine, creates a
torsional bias.
• Asymmetric leg growth has been shown to be common in children,
increasing with the age of the child.
• Leg length discrepancy can be associated with dental malocclusion.
• Mandibular rest position and occlusion will affect head posture.
The cervical spine will compensate for changes within the cranium
affecting whole body posture.
• Correlation with asymmetrical position of heart, liver etc.
Reciprocal function needs to be balanced and integrated to keep these
imbalances under control. If normal imbalances are not regulated by
reciprocal function when walking, turning or breathing, weakness,
instability, breathing pattern dysfunction and painful conditions result.
For example, most humans will keep the pelvis oriented to the right even
when we are on the left foot. The torso will remain rotated to the left
and we will see more posterior arm swing on the left than on the right
during gait.
Breathing
Leon Chaitow3 writes about the effects of Breathing Pattern Disorders
(BPDs) and the connection to chronic conditions of persistent pain and
fatigue such as fibromyalgia, chronic fatigue syndrome, chronic pelvic
pain etc. BPD is described as overbreathing, upper chest breathing and
at extremes, hyperventilation. Breathing may be shallow, rapid with
gasps, sighs, and yawns or breath-holding. Dysfunctional breathing
patterns can be associated with fatigue, dyspnea, panic attacks, anxiety,
and painful musculoskeletal conditions in the upper body.5 Paradoxical
breathing will be occurring when the abdomen is drawn in during
inhalation and moves out during exhalation.4

Polyarticular Chains
In PRI teaching, Ron Hruska describes the common pattern seen in
7 lower extremity orientation. The BCs will influence cervical rotation,
humans as the Left Anterior Interior Chain Right Brachial Chain (LAIC RBC)
pattern.
There are two Brachial chains (BC)
attaching to ribs 4-7, xiphoid and
posterior inferior occipital bone,
anterior inferior mandible and the
corocoid process of the scapula.
They are made up of triangularis
sterni, SCM, scalenes, pec minor,
intercostals and the muscles of the
pharynx and anterior neck.
There are two Anterior Interior
polyarticular muscle chains (AIC),
one on the left and one on the
right, attaching to ribs 7-12, lateral
patella, head of fibula and lateral
condyle of the tibia. They are made
up of the diaphragm, psoas, iliacus,
TFL, biceps femorus and vastus
lateralis.
Figure used with permission from the
Postural Restoration Institute® © 2018,
www.posturalrestoration.com
Modalities
The AICs will influence respiration, trunk rotation, ribcage, spine and
shoulder dynamics and chest expansion during inspiration.
Two Posterior Exterior Chains (PEC) also are present comprising
latissimus dorsi, quadratus lumborum, posterior intercostals, serratus
posterior, and erector spinae group of muscles.
PECs will influence lumbar lordosis, thoracic flatness, sacroiliac strain
and act as accessory muscles of respiration.
L:AIC and R:BC pattern
We commonly see a pattern of overactivity in the left AIC and Right
BC.
• The left side of the pelvis is anteriorly tilted (sagittal plane) and rotated
forward (transverse plane). Right side pelvis is posteriorly tilted.
• Lower back and spine are orientated to the right.
• The centre of gravity is shifted to the right.
• Left hamstrings and ischiocondylar adductor magnus are long and
weak
• Left abdominals are long and weak.
• Right side trunk is shortened.
• Left side anterior ribs are externally rotated (flared) compared with
right.
• Thoracic spine is rotated to the left above T8.
• Cervical spine is rotated and side bent to left.
• Shift of left scapular results in overactive, short pectorals on the left
and increased twist of levator scapula making it more powerfully
positioned.
• Shift of right scapula results in weaker right levator scapulae and
appearance of medial border winging.
• Right SCM is overactive as cervical rotator and also as an accessory
respiration muscle.
Right sided dominance helps to keep us in this pattern. Compensatory
movements in trunk, upper extremities and neck occur which affect rib
alignment and position and affect our ability to breathe. Breathing
pattern dysfunction will often result.
PEC Pattern
Another commonly seen pattern occurs when the pelvis tilts forward
bilaterally. The PEC patterned individual has compensated to increase
airflow into the chest by rotating the right innominate forward as well
as the left. The Posterior Exterior Chain is overactive bilaterally with
anterior ribcage elevated, increased lumbar lordosis and flattening of
the thoracic spine. Weak abdominals on both sides may lead to
paradoxical or belly breathing. Inefficient breathing will encourage rib
flares on both sides and deepening the lumbar lordosis. Rotation of the
pelvis and lumbar spine back to the left and right convexity scoliosis will
commonly occur. Left sided QL pain may present. Breathing pattern
disorders may also be involved.
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 Modalities

The diaphragm The PRI Approach

The diaphragm contracts and flattens on inhale with a decreased
pressure in the thorax drawing air into the lungs. It relaxes on exhale
and is restored to a domed shape pushing air out of the lungs.
The Zone of Apposition (ZOA) is the portion of the diaphragm that is
directly apposed to the inner aspect of the lower ribcage. Core muscle
activation is needed to oppose the diaphragm, maintaining a domed
shape, pulling the ribs down into internal rotation and therefore
maintaining an optimal ZOA.
In the L AIC R BC pattern individual, the left hemi-diaphragm is more
flattened, with suboptimal ZOA and in this position may function more
as a spinal stabilizer than a respiratory muscle. This individual will find
it harder to get air out of the left side and air into the right side of the
chest.6
PRI trained therapists will work to restore optimal ZOA to the left
hemi-diaphragm (for L AIC R BC) or both hemi-diaphragms (for PEC) by
restoring neutral pelvic position, thorax position and retraining scapula-
thoracic musculature.6, 7, 8
• Activation and retraining of IOs (Internal Obliques) and TAs
(Transversus Abdominus).
• Co-contraction of abdominals and hamstrings to restore the
anterior pelvis to neutral in the sagittal plane.
• Activation of ipsilateral adductors and contralateral abductors
works to restore pelvis to neutral in the frontal plane.
• Glut max and glut med activation is employed to stabilise
positioning in the transverse plane.
• Referral to a dentist may at times be needed to address malocclusal
issues.

|| 90-90 Hip Lift

with Right Arm
Reach and Balloon
Zone of Apposition Optimal ZOA Sub-Optimal ZOA

Figures used with permission from the Postural Restoration Institute® © 2018,
www.posturalrestoration.

|| Left Side lying Knee

Toward Knee with Balloon

Optimal PEC Sub-Optimal PEC

Technique images used with

permission from the Postural
Restoration Institute® © 2018,
www.posturalrestoration.com

30 w i n t e r 2 018 | M a s s a g e & M y o t h e r a p y A u s t r a l i a j o u r n a l

The primary aim of PRI work is to restore
proper diaphragmatic function.
The experienced massage therapist or
myotherapist is in an ideal position to recognise
these postural patterns. Understanding the
concepts of PRI has radically changed my
approach to assessment and treatment of my
clients. Leg length discrepancies, scoliosis,
chronic painful conditions, impingement,
fibromyalgia can be explained. Understanding
these concepts has empowered me to help my
clients bring about change in their bodies.
PRI courses were first taught in Australia in
2016 to myotherapists, chiropractors,
osteopaths, physiotherapists and exercise
professionals. A wealth of information can be
found at www.posturalrestoration.com.
Modalities
References
1. Pope R. The common compensatory pattern: Its origin
and relationship to the postural model. AAOJ 14(4):19-40
2. Zink GJ, Lawson WB. An Osteopathic Structural
Examination and Functional Interpretation of the Soma.
Osteopathic Annals 7:12-19. December 1979.
3. Leon Chaitow L, Gilbert C, Bradley D, 2014. Recognizing
and Treating Breathing Disorders - A Multidisciplinary
Approach 2nd Edition, Churchill Livingston, London.
4. Travell J, Simmons D. Myofascial Pain and Dysfunction:
The Trigger Point Manual. Baltimore: Williams and
Wilkins. Vol 1. 1983
5. Perri M, Halford E. Pain and faulty breathing: a pilot
study. JBMT (2004) 8, 297-306
6. Hruska R. Postural Respiration: An Integrated Approach to
Treatment of Patterned Thoraco-Abdominal Pathomechanics
–Training Manual, Postural Restoration Institute®
7. Hruska R. Myokinematic Restoration: An Integrated >>Suzanne has worked as a Remedial Massage
therapist for 22 years, upgrading to
Approach to Treatment of Patterned Lumbo-Pelvic-
Femoral Pathomechanics–Training Manual, Postural Myotherapy in 2016. She practises in
Restoration Institute®
Melbourne and has been an active
8. Henning S, Mangino L, Massé J, 2017.  Innovations in
Spinal Deformities and Postural Disorders. Chap 7,
Ambassador for Massage and Myotherapy
Postural Restoration: A Triplanar Asymmetrical Australia running the Eastern Metro regional
Framework for Understanding, assessing and treating group for 10 years. Suzanne has completed
Scoliosis and other spinal Dysfunctions. four courses of study with the Postural
www.intechopen.com
9. Henning S, Mangino L, Massé J, 2017. Innovations in
Restoration Institute® and is very keen to
Spinal Deformities and Postural Disorders. Chap 7, continue this journey of understanding and
Postural Restoration: A Triplanar Asymmetrical working with patterns of asymmetry in her
Framework for Understanding, assessing and treating clients. Email: suehughes550@gmail.com
Scoliosis and other spinal Dysfunctions.
www.intechopen.com
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